Peer Health Home Care Navigator

Organization: People USA – Non‑Profit Peer Run Behavioral Health, Mental Health, Recovery, Wellness Position: Ulster County Health Home Care Coordinator Job Location: Kingston NY Work Schedule: Monday through Friday – 9:00 AM to 5:00 PM (40 Hours Per Week) Payrate: $24.50 per hour Job Summary The Ulster County care coordinator will work with Medicaid-enrolled individuals, living with mental illness or multiple chronic conditions, to get connected to care and services in their local communities. By connecting high-risk Medicaid individuals to resources and supports, we aim to reduce duplicate services, reduce emergency department visits and inpatient admissions, and lower costs, thus improving the health and well‑being of lives throughout Ulster County. The population served has unmet mental health, addiction or social determinant of health needs and does not typically engage with the traditional systems of care. The goal of the care coordinator will be to work with the participants and their care team in supporting individuals to identify goals and make connections to needed services. Job Responsibilities Assists participants with psychiatric diagnoses to participate in diverse, person‑centered, self‑directed services and meaningful activities that promote empowerment and robust recovery. Collaborating with the SPOA (Single Point of Access) for referrals. Maintains regular contact, outreach, curriculum development, group facilitation, counseling, mentoring, systems navigation, community oversight, and crisis support. Provide Care Management outreach and engagement with eligible individuals in coordination with the Institute of Family Health, and Care Management Partners of Ulster County. Provide screenings and evaluations using trauma‑informed, person‑centered skills with the Institute of Family Health’s service tools, along with individual advocacy, peer support and systems navigation. Educates participants on useful health & wellness topics, including but not limited to Peer/Self‑help, smoking cessation, and advocacy. Resources, Recovery from Mental Health Challenges (from a Psychiatric Rehabilitation perspective), Wellness & Whole Health (SAMHSA’s Eight Dimensions of Wellness), Community Resources (across all domains of health, e.g.: physical, mental, substance use, socio‑economic determinants of health), Trauma & Healing, Wellness Planning & Prevention (e.g. WRAP), Natural Supports (developing/maintaining). Helps participants identify barriers to their recovery journeys or personal wellness, including access, quality of care, people’s rights, lack of basic needs, and stigma & discrimination. Advocates for participants side‑by‑side to overcome identified barriers, making sure their voices are heard, and their decisions are understood and respected. Builds peer‑to‑peer connections/relationships based on mutuality (shared lived experiences), empathy, and hope for recovery/wellness (peers‑as‑proof). Assist Participants to identify & accomplish whole health goals related to the Eight Dimensions of Wellness (emotional, social, physical, environmental, financial, intellectual, occupational, spiritual). Directly connects participants to the services and supports they need through direct bridging/linking (as opposed to referrals only). Develops and maintains positive working relationships with other provider agencies, and local housing providers (landlords) within the county and its surrounding environments. Documents all meaningful interactions with participants in electronic records software and maintains hard copies in participants’ files daily for audit purposes. Responsible for submitting monthly reports on timely manner and attend related meetings. Align all behaviors with core values that promote trauma‑informed care, customer engagement and satisfaction, mutuality & empathy, and a philosophical commitment that everyone can and will recover. Main Job Duties I NDIVIDUAL ADVOCACY : take action to represent the rights and interests of individuals living with mental illness or trauma by removing barriers to their recovery and wellness. PEER SUPPORT : conduct peer support sessions (one‑to‑one, groups) that promote possibilities for positive change, and ultimately help individuals to feel better. Learning materials will be provided when needed. SYSTEMS NAVIGATION : directly support, assist, and guide individuals as they access various resources in the community related to their health, wellness & overall quality of life. DATA ENTRY : Using Epic Compass Rose regularly for documentation and billing requirements. WHOLE HEALTH & WELLNESS NEEDS ASSESSMENTS & INTEGRATION STRATEGIES : Assess clients’ needs, educating them on all community‑based resources to help with needs (from a menu of internal & external services & supports), directly linking them to those resources, and working to ensure that they have quality, integrated care. CARE MANAGEMENT SERVICES : Questions about health care, managing stress, making & remembering appointments, medications, food, transportation, housing, health insurance, and other services as needed. OFFICE DUTIES : Maintain timely and accurate documentation, files, and databases; compile and submit program statistics and reports; and attend weekly supervisory meetings. Staff will also participate in mandatory professional development and training. May include other duties as they arise. Job Requirements & Qualifications This position requires a thorough understanding of the process and the possibility of robust recovery for people diagnosed with psychiatric disabilities. People with personal experience as a recipient of mental health services and/or of personal recovery are preferred. Knowledge of ADA, mental health laws and systems, Social Security Programs, Work Incentives, Entitlement Programs, supported employment, Federal/state/local services, laws, and systems related to individuals with disabilities. Demonstrated ability to recognize the need for and facilitate connections between participants and services. Knowledge of local, statewide, and national disability‑related issues and community dynamics. Excellent written and verbal presentation skills. Ability to obtain the NYS Peer Specialist Certification within 6 months of active employment. MUST HAVE A VALID AND CLEAN DRIVERS LICENSE. Educational and Experience Requirements (1.) A Master’s degree in one of the qualifying fields and one (1) year of experience; OR (2.) A Bachelor’s degree in one of the qualifying fields and two (2) years of experience; OR (3.) A Bachelor’s degree or higher in ANY field with either: three (3) years of experience, or two (2) years of experience as a Health Home care manager serving the SMI or SED population or (4.) A Credentialed Alcoholism and Substance Abuse Counselor (CASAC) and two (2) years of experience. Qualifying Fields: include education degrees featuring a major or concentration in: social work, psychology, nursing, rehabilitation, education, occupational therapy, physical therapy, recreation or recreation therapy, counseling, community mental health, child and family studies, sociology, speech and hearing or other human services field. Experience shall consist of (1.) Providing direct services to people with Serious Mental Illness, developmental disabilities, alcoholism or substance abuse, and/or children with SED; OR (2.) Linking individuals with Serious Mental Illness, children with SED, developmental disabilities, and/or alcoholism or substance abuse to a broad range of services essential to successful living in a community setting (e.g. medical, psychiatric, social, educational, legal, housing and financial services). Reports to - Director of Care Coordination & Advocacy Services #J-18808-Ljbffr